Telehealth technologies provide opportunities to increase access to healthcare for individuals who are not located in proximity to high-quality care. The Centers for Medicare & Medicaid Services defines telemedicine as two-way audio and video interactive communication, which is specifically covered by the Military Health System, when appropriate and medically necessary for beneficiaries. The application of telecommunication technologies allows providers and healthcare systems to create new methods or more efficient structures for the delivery of care. In this chapter, the committee reviews the studies on cognitive rehabilitation therapy (CRT) interventions for a range of deficits due to traumatic brain injury (TBI) applied through telehealth technology applications.
The committee reviewed six randomized controlled trials (RCTs) (Bergquist et al. 2009, 2010; Bourgeois et al. 2007; Dou et al. 2006; Ownsworth and McFarland 1999; Salazar et al. 2000; Soong et al. 2005) and four feasibility or pilot studies (Bergquist et al. 2008; Diamond et al. 2003; Egan et al. 2005; Melton and Bourgeois 2005) that involved a telehealth technology whereby parts of the intervention were delivered remotely. Five of the studies did not meet eligibility criteria because they either did not evaluate a CRT intervention (Egan et al. 2005), they evaluated a limited outcome related only to feasibility or the task being taught
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12 Telehealth Technology OVERVIEW Telehealth technologies provide opportunities to increase access to healthcare for individuals who are not located in proximity to high-quality care. The Centers for Medicare & Medicaid Services defines telemedicine as two-way audio and video interactive communication, which is specifically covered by the Military Health System, when appropriate and medically necessary for beneficiaries. The application of telecommunication technolo- gies allows providers and healthcare systems to create new methods or more efficient structures for the delivery of care. In this chapter, the committee reviews the studies on cognitive rehabilitation therapy (CRT) interventions for a range of deficits due to traumatic brain injury (TBI) applied through telehealth technology applications. CRT APPLIED THROUGH TELEHEALTH TECHNOLOGY The committee reviewed six randomized controlled trials (RCTs) (Bergquist et al. 2009, 2010; Bourgeois et al. 2007; Dou et al. 2006; Ownsworth and McFarland 1999; Salazar et al. 2000; Soong et al. 2005) and four feasibility or pilot studies (Bergquist et al. 2008; Diamond et al. 2003; Egan et al. 2005; Melton and Bourgeois 2005) that involved a telehealth technology whereby parts of the intervention were delivered remotely. Five of the studies did not meet eligibility criteria because they either did not evaluate a CRT intervention (Egan et al. 2005), they evalu- ated a limited outcome related only to feasibility or the task being taught 243
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244 COGNITIVE REHABILITATION THERAPY FOR TBI (Bergquist et al. 2008; Diamond et al. 2003; Melton and Bourgeois 2005), or the etiology of the brain injury of participants was not specified as trau- matic (Soong et al. 2005). Studies included in the telehealth technology review are not mutually exclusive from trials included in the evaluations of other domains. Of the remaining five studies, one was a small, randomized crossover study that involved 20 volunteers with a history of moderate-severe trau- matic brain injury (TBI) at least 1 year prior to study entry (Bergquist et al. 2009, 2010). Individuals with a history of ongoing psychiatric symp- toms were included as long as symptoms were not severe (e.g., psychotic symptoms). Participants, who had to have reliable access to the Internet, were randomized to an active cognitive rehabilitation intervention or to a control group. After completing 30 instant messaging sessions with online therapists, participants were crossed over to the alternate group for 30 more sessions. The active intervention, which involved an online occupational therapist with expertise in cognitive rehabilitation, focused on developing calendar skills to address difficulties with memory in everyday life and on developing strategies to improve memory functioning. The control group also involved interaction with the online therapist, but participants in this group were instructed primarily to use their calendar to record day-to-day events rather than using calendars as a compensatory tool for memory im- pairments. Only 14 participants completed the study. Outcome measures were self-reported measures that assessed use of compensation strategies (Compensation Techniques Questionnaire) and satisfaction with therapy, and measures completed by family members (Neurobehavioral Functioning Inventory and Compensation Integration Questionnaires). All participants reportedly learned to use the instant messaging system. Most individuals in both groups were satisfied with their Internet-based interventions. No statistically significant differences in change in daily function were reported between groups after 30 sessions. Another modest-sized trial involved adults with persisting memory problems several years after a documented closed head injury (Bourgeois et al. 2007). The trial also required a family member to participate with the patient. Participant-caregiver pairs were assigned to either spaced retrieval training or a didactic control strategy using stratified pairing based on race and sex (quasi-experimental). Both treatments were delivered via telephone by clinician trainers. After initial face-to-face assessments of cognitive dif- ficulties and social participation activities, the trained discussed treatment goals with the client and caregiver, and the group selected the three most troublesome areas to work on during training. The trainer then provided memory logs and asked patients and caregivers to record the frequency with which each problem occurred over the next week. The trainer called partici- pants the following day to make sure that instructions and data collection
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245 TELEHEALTH TECHNOLOGY methods were understood. The trainer then called participants four to five times each week for 30-minute sessions. Participants in the spaced retrieval group received an instructional technique focused on selected goals. The therapist modeled correct responses to questions related to the goals and instructed the participants not to struggle to retrieve responses, but to re- spond immediately. Participants in the control arm received the same total amount of therapy time and sessions that focused on memory strategies such as association, verbal rehearsal, imagery and written reminders. Out- comes included goals mastered, generalization, the frequency of reported memory problems, a cognitive difficulties scale, and community integration and quality of life measures. Immediately and at 1 month posttraining, the space retrieval group (and their caregivers) reported more treatment goal mastery and use than the didactic instruction group (and their caregivers). Both groups reported some generalization to other nontargeted behaviors, but these improvements were not statistically significantly different be- tween groups. There were no reported important or statistically significant improvements in quality of life for either group. One limitation was that data about “objective, observable behaviors” related to selected goals was obtained from memory logs, and those data were sometimes incomplete. Of the 51 pairs who agreed to participate, only 38 completed the study: 22 spaced-retrieval training pairs and 16 didactic control pairs. Another small randomized trial involved 20 patients, most of whom had sustained a brain injury from a motor vehicle accident many years before (Ownsworth and McFarland 1999). The severity of the brain injury was not described. The trial compared two different approaches to training individuals to use a dairy to compensate for memory problems (a diary only approach and a diary and self-instructional approach that taught compen- sation using higher cognitive skills of self-awareness and self-regulation). In one session, some instructions for daily memory checklists were given verbally over the phone to both groups, but the 4-week intervention period mainly involved self-use of diaries. Follow-up phone calls to monitor prog- ress or provide additional instruction were not included during the inter- vention phase of the study. Findings showed that the self-instruction group consistently made more diary entries and reported less memory problems than the diary only group. Another trial involved 30 patients with memory disorders and a history of TBI who had had neurosurgery several months prior (Dou et al. 2006). Patients who had a history of previous psychiatric problems or who were computer phobic were excluded. Participants were randomly assigned to one of the following three groups: computer assisted memory training, therapist assisted memory training, and no specific memory training (the control group). In the computer assisted training, patients were asked to identify or define the information they needed help from a therapist to
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246 COGNITIVE REHABILITATION THERAPY FOR TBI learn. The computer provided the necessary information for the patients to generate correct decisions through an errorless approach. The patients were not encouraged to engage in guesswork and were told to consider alternatives to and the consequences of an intended action. The therapist assisted training covered similar content, but the content was presented as a picture album and therapists gave directions face to face. The train- ing consisted of 20 45-minute sessions occurring 6 days a week. Training was aimed at compensatory techniques related to memory, management of typical daily tasks, and utilizing typical component memory skills. One month after treatment, both treatment groups improved on two outcome assessments (Neurobehavioral Cognitive Status Examination, Rivermead Behavioural Memory Test) compared to the control group, though both treatment groups improved similarly. The largest trial involved 120 active-duty military personnel who had recovered sufficiently from a recent moderate-severe closed head injury (within 3 months of randomization) to participate in a cognitive rehabili- tation program or safely return home with a caregiver (Salazar et al. 2000, with Braverman et al. 1999 and Warden et al. 2000). All were oriented and had a Rancho Los Amigos cognitive level of 7. Most had headaches. About a third of the participants were described as having aggressive behavior or major depression, though few were taking psycho-trophic medications. Participants were randomly assigned to a comprehensive 8-week in-hospital cognitive rehabilitation program or a limited educa- tional and counseling home rehabilitation program with weekly telephone support from a psychiatric nurse. During the telephone calls, which were described as lasting 30 minutes, nurses inquired about the week’s events and offered support and advice in addressing problems. Of the 67 partici- pants assigned to the in-hospital program, 60 completed the program; 47 of the 53 assigned to the home program completed the trial. Six patients assigned to home rehabilitation required supplemental therapy. Cogni- tive behavioral function assessed with various measures was similar for both groups at baseline and at 1-year follow-up. More than 90 percent of the participants in both groups had returned to work (the primary outcome measure) 1 year after treatment (the difference between groups was 4 percent, [95 percent confidence interval, 5 to 14 percent]). Quality of life measures including belligerence, social irresponsibility, anti-social behavior, social withdrawal, and apathy were reported as not statisti- cally significantly different between groups at 1 year, but only 32 of the intensive rehabilitation group and 28 of the home rehabilitation group completed those assessments.
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247 TELEHEALTH TECHNOLOGY CONCLUSIONS: TELEHEALTH TECHNOLOGY This scant evidence base shows that telehealth technologies, including telephone and two-way messaging, are feasible means of providing at least part of CRT for some patients. No studies evaluated the use of telemedicine, as defined by the Centers for Medicare & Medicaid Services as two-way audio and video interactive communication. Overall evidence is insufficient to clearly establish whether telehealth technology delivery modes are more or less effective or more or less safe than other means of delivering CRT. However, when combined as part of a broader CRT program, telehealth technologies, including telephone calls, can contribute to outpatient treat- ment programs with comparable results to inpatient programs for selected individuals. REFERENCES Bergquist, T., C. Gehl, S. Lepore, N. Holzworth, and W. Beaulieu. 2008. Internet-based cog- nitive rehabilitation in individuals with acquired brain injury: A pilot feasibility study. Brain Injury 22(11):891–897. Bergquist, T., C. Gehl, J. Mandrekar, S. Lepore, S. Hanna, A. Osten, and W. Beaulieu. 2009. The effect of Internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury. Brain Injury 23(10):790–799. Bergquist, T. F., K. Thompson, C. Gehl, and J. M. Pineda. 2010. Satisfaction ratings after receiving Internet-based cognitive rehabilitation in persons with memory impairments after severe acquired brain injury. Telemedicine and e Health 16(4):417–423. Bourgeois, M. S., K. Lenius, L. Turkstra, and C. Camp. 2007. The effects of cognitive tele- therapy on reported everyday memory behaviours of persons with chronic traumatic brain injury. Brain Injury 21(12):1245–1257. Braverman, S. E., J. Spector, D. L. Warden, B. C. Wilson, T. E. Ellis, M. J. Bamdad, and A. M. Salazar. 1999. A multidisciplinary TBI inpatient rehabilitation programme for active duty service members as part of a randomized clinical trial. Brain Injury 13(6):405–415. Diamond, B. J., G. M. Shreve, J. M. Bonilla, M. V. Johnston, J. Morodan, and R. Branneck. 2003. Telerehabilitation, cognition and user-accessibility. Neurorehabilitation 18(2):171–177. Dou, Z. L., D. W. K. Man, H. N. Ou, J. L. Zheng, and S. F. Tam. 2006. Computerized er- rorless learning-based memory rehabilitation for Chinese patients with brain injury: A preliminary quasi-experimental clinical design study. Brain Injury 20(3):219–225. Egan, J., L. Worrall, and D. Oxenham. 2005. An Internet training intervention for people with traumatic brain injury: Barriers and outcomes. Brain Injury 19(8):555–568. Melton, A. K., and M. S. Bourgeois. 2005. Training compensatory memory strategies via the telephone for persons with TBI. Aphasiology 19(3-5):353–364. Ownsworth, T. L., and K. McFarland. 1999. Memory remediation in long-term acquired brain injury: Two approaches in diary training. Brain Injury 13(8):605–626. Salazar, A. M., D. L. Warden, K. Schwab, J. Spector, S. Braverman, J. Walter, R. Cole, M. M. Rosner, E. M. Martin, J. Ecklund, and R. G. Ellenbogen. 2000. Cognitive rehabilitation for traumatic brain injury: A randomized trial. Journal of the American Medical Associa- tion 283(23):3075–3081.
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248 COGNITIVE REHABILITATION THERAPY FOR TBI Soong, W., S. F. Tam, W. K. Man, and C. Hui-Chan. 2005. A pilot study on the effectiveness of tele-analogy-based problem-solving training for people with brain injuries. International Journal of Rehabilitation Research 28(4):341–347. Warden, D. L., A. M. Salazar, E. M. Martin, K. A. Schwab, M. Coyle, and J. Walter. 2000. A home program of rehabilitation for moderately severe traumatic brain injury patients. The Journal of Head Trauma Rehabilitation 15(5):1092–1102.